Subjective: This 17-year-old patient presents to the emergency department after racing motorcycles earlier today. He had his helmet on as well as all of his racing gear. He actively races motorcycles and has done this all summer long, winning a number of times. He came over a jump and lost control of the bike, going over the handlebars. He denies hitting his head but landed on his left elbow and his left knee and has had some discomfort in these areas since. He tells me that he was not going fast, approximately 30 mph. He denies any loss of consciousness. The main complaints center only on the left knee and the left elbow.
Objective: The patient is in no acute distress, nontoxic appearing. During an expanded problem-focused examination, he is alert and oriented.
Eyes: PERL, EOMI conjugate without nystagmus. Funduscopic exam reveals the discs to be sharp and the TMs normal. Throat: clear with teeth intact. Neck: nontender. No palpable discomfort or adenopathy. He has intact clavicles. Lungs: clear. Heart: regular rate and rhythm. Abdomen: soft; no hepatosplenomegaly, rebound, or guarding. He has good upper- and lower-extremity strength. His right arm is nontender to palpation. The left arm has a small amount of tenderness around the elbow joint, but there is no obvious deformity and he does have good, active motion. He has no tenderness with movement of the hips and no tenderness down the long bones of the lower extremities. There is mild tenderness at the left knee. The knee is intact with negative drawer sign and minimal tenderness along the lateral collateral ligament region. There is no real tenderness along the joint line or over the mediocollateral ligament. Both of these ligaments are intact with stress. X-rays of the left knee and left elbow are negative for fracture.
Assessment: Contusion, left elbow and left knee (the MDM was of low complexity).
Plan: Ice, Tylenol; recheck if not improving over the next few days, otherwise on a prn basis.
CPT Code: ____________________
99282
This patient is seen in the clinic at the request of Dr. Jones for evaluation of suprapubic pain. Patient is a 22-year-old black female G1 P0, LMP 12/20/xx, EDC 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation. Presents with complaint of suprapubic sharp to mild pain with onset 2 months ago. Pain has become progressively worse. Patient has been seen by Dr. Jones for this pregnancy and has also been seen by Dr. Smith for this current complaint 2 weeks ago. Patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge. Labs: CBC and urinalysis performed. Allergies: none. Past medical history: genital wart 1986. Past surgical history: wart removed by laser 1986. Social history: no smoking, illicit drugs, or alcohol.
PE: During an expanded problem-focused examination, the HEENT was found to be normal. FHT: A 148, B 146. Heart: normal. Lungs: CTA. Abdomen: gravid 20 cm. Slight tender suprapubic region. Vaginal exam: closed cervix, thick, long; no discharge. Extremities: negative for edema; UA loaded with bacteria and WBC.
Impression: 1. IUP at 18 weeks with twin gestation. 2. Acute UTI (the MDM was straightforward).
Recommendation: Keflex, 500 mg, and follow-up with Dr. Jones.
CPT Code: ____________________
99242
This is a 79-year-old right-handed married female, who I am now hospitalizing for evaluation of recurrent episodes of numbness and weakness of left upper extremity.
This patient relates to having two episodes occurring during the last week of June; both of these occurred while she was eating breakfast around 7:30 AM. She developed sudden onset, without warning, of complete paralysis as well as numbness of the left arm, which lasted for 10 to 15 minutes. There was no speech impairment, no involvement of the face or leg, and no associated headache. These symptoms completely returned to normal. She denies associated chest pain, shortness of breath, or tachycardia with these spells, and there was no jerking of the extremities. About 2 days later, she again had a similar spell. She has not had any further episodes since that time.
Patient's history is significant for hypertension since age 35. She had no previous history of heart disease or diabetes. Two years ago she was seen by Dr. Smith for left putamen hemorrhage. Patient was also found to have right meningioma arising near the petrous region. She describes about 8 episodes over the past 10 years when her right peripheral vision blacked out briefly. She could not recall whether either eye was affected or if this was the right peripheral vision. The last such episode was about 4 months ago.
This past winter she also had about a 2-week period when the right foot seemed to drag. There has been no recent head injury, and there is no prior history of seizures.
Recent carotid Doppler study performed showed moderate calcified plaque in the right carotid bulb but no significant lesion. No flow could be found in the left internal carotid artery, suggesting left internal carotid artery occlusion. Calcified plaque was also noted in the left carotid bulb. Repeat CT scan of the head again showed the old area of infarction involving the left basal ganglia. There was an enhancing lesion starting in the right tentorial region and extending upward into the right parietal area, having the appearance of a meningioma. This is basically unchanged from the previous scan.
Past Medical History: No serious illnesses.
Operations: 1. Hysterectomy and bladder repair
2. Bilateral blepharoplasty
3. D&C times 4
Allergies: None
Medications: 1. Hytrin, 5 mg, one daily
2. Lozol, 2.5 mg, one daily
Tobacco: Does not smoke
Alcohol: Occasional
Education: Bachelor's degree
Review of Systems: No recent head trauma, blackout spells, or seizures; no recent problems with headaches
Eyes: As noted
ENT: Negative
Respiratory: Negative
Cardiovascular: Negative except for hypertension
GI/GU: Negative
Endocrine: No diabetes or thyroid problems
Musculoskeletal: Some arthritis, both hands
Psychological: Negative
Family history: Mother deceased from heart disease; father had multiple strokes; two brothers, one with polio; three children whose health is good
Physical Examination: Very pleasant elderly female, in no distress at this time
Vitals: Blood pressure is 140/84; pulse, 90; 150/90
Left arm sitting position
Weight: 115
Skin: No skin lesions present
Nodes: No lymphadenopathy
Chest: Clear to auscultation
Cardiac: Reveals a regular rhythm; I did not hear any murmurs or gallops
Abdomen: Soft, no masses
Back: Negative
Extremities: Negative
Higher cortical function: Intact; speech is fluent
Cranial nerves II-XII: Intact; pupils are equal, reactive to light both direct and consequently; confrontation fields are intact; funduscopic exam was normal; ocular sensation is intact; there is no facial paresis or droop
Reflexes: 1/1 throughout; plantar responses are downgoing bilaterally
Motor/tone/strength: Felt to be normal throughout with particular attention paid to the left upper extremity
Sensory: Reveals no sensory deficits, again with attention paid to the left upper extremity
Coordination: Normal
Gait: Reveals no abnormalities; she is able to walk on heels and toes without difficulty; tandem walk is normal; Romberg is negative
Impression: (1) recurrent episodes of left upper-extremity paralysis and numbness; subclavian steal syndrome (Moderate MDM)
Plan: Extensive neurological workup
CPT Code: ____________________
99222
This is a 15-year-old girl, never seen at this clinic. During a problem-focused history, she states that she noticed a lump on the back of her right wrist yesterday.
P/E: There is a 2-cm freely movable, rubbery, round swelling on the dorsal surface of the right wrist. Distal neurovascular and tendon exam intact. This is not painful to palpation. (The MDM was of straightforward complexity.)
Impression: Ganglion cyst, right wrist.
Treatment: Refer to Dr. Andrews for further treatment.
CPT Code: ____________________
99201
A new patient presents to the physician's office at which time the physician provides a comprehensive history and exam with a high complexity MDM.
CPT Code: ____________________
99205
An initial inpatient consultation with a detailed history, detailed exam and MDM of low complexity.
CPT Code: ____________________
99253
A 40-year-old established patient presents to the physician office for a preventive care exam.
CPT Code: ____________________
99396
History and exam of the normal newborn infant born in a hospital setting.
CPT Code: ___________________
99460
A 7-year-old female established patient presents to the pediatrician complaining of ear pain x 3 days. A detailed history is then taken. She had associated fever of 101° F yesterday. Mom treated her with Tylenol. The fever this AM is 99° F. She has had some chills and cough as well as some difficulty breathing. No nausea or vomiting. No prior history of Otitis. Brother was sick earlier this week. The physician performed a detailed exam of the ENT as well as a limited exam of GI, Lungs, and Heart. Vital signs were taken in the office. The physician diagnosed the patient with Otitis Media and an Upper Respiratory Infection and prescribed an antibiotic. The MDM is stated to be moderate.
CPT Code: ____________________
99214
CLINIC NOTE
CC: Patient presents for routine examination
SUBJECTIVE: Sally is a 42-year-old female patient who presents today for a routine physical examination
OBJECTIVE: BP 120/80. Pelvic exam: normal external genitalia. Vagina without discharge except for a scant amount of white discharge that appears normal. Cervix: Multiparous, clear. Bimanual exam is unremarkable. All systems are within normal limits.
ASSESSMENT:
1. Normal BP.
2. Normal pelvic exam.
PLAN: Return in 1 year or as needed.
CPT Code: ____________________
99396
Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald's residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. The medical decision making is straightforward.
CPT Code: ____________________
99341
Location: Emergency Room
SUBJECTIVE: This is a 38-year-old female who presents to the emergency room with a history of currently being under treatment for a right corneal abrasion that occurred on Sunday. She states she was seen by the "eye doctor earlier today" and now has a bandage over her eye. Apparently her eye is opened underneath the bandage and she is unable to close her eyelid. She feels her eyelid is stuck to the bandage.
OBJECTIVE: She is afebrile with stable vital signs. The patch was removed and there was a folded piece of Telfa that had slipped down and her upper eyelid was unable to close over the top of this. The Telfa was removed and a wet patch was placed. This did provide significant comfort. Her eye patch was reinforced.
ASSESSMENT: 1. Right corneal abrasion under treatment. 2. Eye patch replaced as described above.
PLAN: She has a follow up visit tomorrow morning with ophthalmology. I told her she needs to keep that appointment. She is to return here sooner if she is having increasing problems.
CPT Code: ____________________
99281
Location: Emergency Room
SUBJECTIVE: A 32-year-old female who presents to the emergency department with chief complaint of increased postoperative swelling. This patient had right neck lymph node biopsy done 3 days ago. Patient has a dressing in place ever since then. For the past 24 hours, she feels like she has increased swelling and she presents now because of it. She denies any accompanying fever, chills, or sweats.
PAST MEDICAL HISTORY: No known drug allergies. Only surgery was wisdom tooth extraction 1 month ago and then the recent lymph node biopsy. Medically, she has a history of depression.
REVIEW OF SYSTEMS: Respiratory: She denies dyspnea.
OBJECTIVE: This is an alert 32-year-old female who appears to be in no acute distress. Temperature is 35.7, pulse 90, respirations 18, blood pressure 144/105, oxygen saturation 99%. HEENT: Conjunctivae and lids normal. Mouth well hydrated. Pharynx normal. Neck is supple. I have removed the dressing. There is a Pen Rose drain in place. The wound seems to be healing well. There is some soft tissue swelling which extends about 3 cm from the wound itself. There is no erythema and no warmth to the area.
ASSESSMENT: Postoperative swelling.
PLAN: I have discussed the case with the ENT surgeon. We have redressed the area. Patient is reassured and will be following up with her doctor tomorrow for drain removal.
CPT Code: ____________________
99282
Location: Hospital
PROGRESS NOTE
The patient is seen today. She has been transferred from the ICU to the floor. She has essentially stabilized. Again, she is having some type of seizure activity.
PHYSICAL EXAMINATION: Her vitals overall are fairly well stabilized. Her postoperative dressings are in place. She did have a significantly elevated INR so
the dressings have been kept in place to minimize the risk of bleeding. She was sleeping when I saw her so I did not wake her. Her toes are pink and warm. Calves are soft.
IMPRESSION: Seizure, status post left hip bipolar hemiarthroplasty.
PLAN: I will continue to follow. From my standpoint, she can mobilize and weight bear as tolerated on the left side. We will change her dressings and place TED hose on the left. We will continue to follow her INR and hemoglobin. Of note, she has been made code status II.
CPT Code: ____________________
99231
Anesthesia for diagnostic arthroscopic procedure of the knee joint.
CPT Code: ____________________
01382
Daily hospital management of epidural, continuous drug administration.
CPT Code: ____________________
01996
Assign a CPT anesthesia code for debridement of third-degree burns of right arm, 6% body surface area.
CPT Code: ____________________
01952
Assign a CPT anesthesia code for total hip replacement, open procedure.
CPT Code: ____________________
01214